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Introduction

Among cancers that affect both men and women, colorectal cancer is the second leading cause of cancer death (1). In 2007 (the most recent year for which data are available), >142,000 persons received a diagnosis for colorectal cancer and >53,000 persons died (1). Screening for colorectal cancer has been demonstrated to be effective in reducing the incidence of and mortality from the disease (2). In 2008, the U.S. Preventive Services Task Force (USPSTF) recommended that persons aged 50–75 years at average risk for colorectal cancer be screened by using one or more of the following methods: high-sensitivity fecal occult blood testing (FOBT) every year, sigmoidoscopy every 5 years with FOBT every 3 years, or colonoscopy every 10 years (2).

The effectiveness of screening in reducing the incidence and mortality of colorectal cancer has been well established (2). Colorectal cancer screening has been identified as a high-impact, cost-effective service (3,4). An estimated 10,000 additional deaths could be prevented each year if all adults aged ≥50 years were offered colorectal cancer screening, at an estimated cost of $11,900 per life year saved (3). Modeling studies have suggested that increasing colorectal cancer screening would have the greatest impact in reducing colorectal cancer mortality, compared with reducing risk factors or increasing treatment use (5,6). Despite strong evidence of its effectiveness, colorectal cancer screening prevalence continues to lag behind that of other screening-amenable cancers (i.e., breast and cervical cancer) (7,8).

This report summarizes the prevalence of colorectal cancer screening test use that can be used as a baseline by providers, public health practitioners, and other stakeholders to assess progress in colorectal cancer screening rates as the Patient Protection and Affordable Care Act (ACA) of 2010 (as amended by the Healthcare and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) is fully implemented (9).

Methods

To determine the state-based prevalence of colorectal cancer screening among U.S. adults, CDC analyzed 2010 data from the Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is an ongoing, state–based, random-digit–dialed telephone survey of the U.S. civilian, noninstitutionalized adult population aged ≥18 years that collects information on health risk behaviors, preventive health practices, and health-care access in the United States, the District of Columbia (DC), Guam, Puerto Rico, and the U.S. Virgin Islands. Every 2 years (in even-numbered years) respondents aged ≥50 years are asked whether they have ever used a "special kit at home to determine whether the stool contains blood (FOBT)," whether they have ever had "a tube inserted into the rectum to view the colon for signs of cancer or other health problems (sigmoidoscopy or colonoscopy)," and when these tests were last performed. Starting in 2008, respondents also were asked whether their most recent test had been a sigmoidoscopy or a colonoscopy. Percentages were estimated for persons who reported receiving an FOBT within 1 year, or sigmoidoscopy within 5 years with FOBT within 3 years, or colonoscopy within 10 years preceding the survey. Based on the USPSTF recommended screening age, the analysis was restricted to persons aged 50–75 years.

Survey data were available for all 50 states and DC. Based on Council of American Survey and Research Organizations (CASRO) guidelines,* in 2010, the median response rate was 54.6% (range: 39.1%–68.8%), and the median cooperation rate was 76.9% (range: 56.8%–86.1%). Respondents who refused to answer, had a missing answer, or did not know the answer to a question were excluded from analysis of that specific question. Of 236,186 persons aged 50–75 years who responded, approximately 12,206 (5.2%) were excluded from the results, yielding a final sample of 223,980. Data were weighted to the age, sex, and racial/ethnic distribution of each state's adult population using intercensal estimates and were age-standardized to the 2010 BRFSS population.

Results

In 2010, an estimated 64.5% of respondents aged 50–75 years reported having had one of the following colorectal screening tests recommended by USPSTF: FOBT within 1 year, sigmoidoscopy within 5 years with FOBT within 3 years, or colonoscopy within 10 years preceding the survey (Table 1). The proportion of respondents who reported having had a colorectal cancer test within the recommended interval increased with age, increasing education level, and increasing annual household income. The proportion was also greater for those with health insurance than for those without, those with a regular care provider than those without, and slightly greater for women than for men. A slightly greater proportion of whites reported being up-to-date with colorectal cancer testing compared with all other racial/ethnic groups.

The proportion of respondents who had colonoscopy as their most recent test (60.3%) was much greater than the proportion that had FOBT (11.7%) or sigmoidoscopy in combination with FOBT (1.3%) as their most recent test. The proportion reporting use of any of the three test options increased with age and was greater among those with insurance and those with a regular care provider. Although a very small proportion of respondents reported having had a sigmoidoscopy within 5 years with FOBT within 3 years, a slightly greater proportion reported having had a sigmoidoscopy alone within 5 years (5.7% [95% confidence interval (CI) 5.4%–5.9%]; data not shown). A greater proportion of blacks reported receiving FOBT within 1 year compared with all other members of racial/ethnic groups; a greater proportion of whites reported colonoscopy within 10 years compared with all other racial/ethnic groups. Minimal variation was noted in reported FOBT use by education level and household income, whereas the proportion of respondents reporting colonoscopy within the past 10 years increased substantially with increasing education level and increasing annual household income.

The proportion of respondents who reported having received any colorectal cancer test within the recommended interval was highest in Massachusetts (75.2%) and in New Hampshire (75.1%) and lowest in Oklahoma (54.1%) (Table 2). Connecticut had the largest proportion of respondents who reported colonoscopy within 10 years (72.5%), and West Virginia had the smallest (49.7%). California had the largest proportion of respondents who reported FOBT within 1 year (19.4%), and Utah had the smallest (4.7%). All states had <5% of respondents reporting receiving sigmoidoscopy within 5 years and FOBT within 3 years.

Discussion

Approximately two thirds of the U.S. population aged 50–75 years was up-to-date with colorectal cancer screening according to USPSTF recommendations. As noted in previous reports, certain populations had a lower prevalence of colorectal cancer screening, including those with a lower socioeconomic status, lower education levels, Hispanics, and those without health insurance or a regular health care provider (10–12). These populations also had a lower prevalence of screening with colonoscopy, despite evidence that colonoscopy has rapidly become the predominant method of colorectal cancer screening in the United States (8). This might reflect variation in access to colonoscopy by traditionally underserved populations. Substantial variation existed by state in the proportion of respondents who were up-to-date with colorectal cancer screening. In general, states with the highest proportion of residents who were current with screening also had the highest proportion of residents who reported colonoscopy as their most recent test. Use of FOBT and sigmoidoscopy with FOBT was low in all states. Variation in colonoscopy use by state might result from variations in the level of insurance coverage, proportion of underserved populations in the state, and availability of endoscopists (13,14).

An understanding of what factors influence the use of colorectal cancer screening is necessary to make improvements. Lack of insurance has been cited frequently as a barrier to colorectal cancer screening (12,15,16). Multiple studies have noted significantly lower colorectal cancer screening prevalence among the uninsured (10–12). The cost of a screening colonoscopy can range between $400 and $1,600 (17,18). FOBT kits themselves are relatively inexpensive, but additional costs incurred by office visits and any potential follow up testing with colonoscopy could be cost prohibitive. Further, the uninsured might not have a regular health care provider from whom to receive a recommendation or referral for testing. Full implementation of the Afforable Care Act will potentially provide millions of currently uninsured persons with coverage of clinical preventive services graded A or B by the USPSTF, such as colorectal cancer screening (graded A for adults aged 50–75 years), without additional copays, thereby removing a substantial financial barrier. Colorectal cancer screening for those currently insured by Medicare also should increase, as the Afforable Care Act removed cost-sharing for USPSTF grade A or B services as well as Advisory Committee on Immunization Practices (ACIP)-recommended immunizations as of January 1, 2011 (ACA §2713). The law provides for an enhanced federal match rate to state Medicaid programs that offer these services at no cost sharing, beginning January 1, 2013 (ACA §4106) .

Although substantial gains in colorectal cancer screening rates have been made over the past 10 years (from 54% in 2002 to approximately 65% in 2010), for the full potential of screening to be reached, additional work is needed to increase the uptake of screening among the currently insured and soon-to-be insured (10). Access to a regular health-care provider and having health insurance were each associated with a substantially higher prevalence of colorectal cancer screening; however, the prevalence of colorectal cancer screening has remained lower than screening rates achieved with breast and cervical cancer screening, even among the currently insured (7,8). Participation in screening is influenced by multiple factors at the individual, physician, and organizational levels (19). Individual level barriers include lack of a physician recommendation, lack of knowledge, fear, embarrassment, lack of symptoms or current health problems, cost, and competing demands (20,21). Barriers also might vary by test type. Reported barriers to FOBT include not wanting to handle stool or keep stool cards in the house (20,22). Colonoscopy-specific barriers include fear or avoidance of bowel preparation, fear of having a tube inserted through the rectum, and fear of pain or discomfort (20). Providers also might preferentially recommend a particular test to patients, which might deter patients who would prefer an alternate test option from following through with screening (21).

Provider barriers to colorectal cancer screening include lack of knowledge of current screening guidelines, forgetfulness, competing priorities in the care of the patient (e.g., active comorbid diseases), patient refusal, lack of time, lack of a reminder system, and lack of tracking and follow up systems (15,23). Physicians also might overestimate the frequency with which they recommend colorectal cancer screening to their patients because patients often cite lack of a physician recommendation as the reason they did not complete screening (19,23).

Health-care system and organizational barriers, other than financial barriers, also exist. Absence of office systems that facilitate identification and referral of patients eligible for screening, insufficient access to primary care providers, insufficient access to or misdistribution of endoscopists, and structural barriers (e.g., lack of transportation, lack of translation services, or availability of screening services only during working hours) can impede access to screening even if provider- and patient-level barriers have been addressed (24–26).

Evidence-based interventions that address many of these barriers exist. The Guide to Community Preventive Services (known as the Community Guide) (available at http://www.thecommunityguide.org/cancer/index.html) has identified client- and provider-oriented interventions that have been demonstrated to increase cancer screening rates (26). Client-oriented interventions (e.g., client reminders, small media, and reducing structural barriers) can address a variety of barriers by, for example, augmenting or replacing a physician recommendation with a reminder, providing patient education about test choices, increasing knowledge about the importance of colorectal cancer screening, or providing screening services after working hours. Provider-oriented interventions (e.g., assessment and feedback or reminder and recall systems) can increase knowledge of current screening guidelines, inform actual screening rates among patients, and create institutionalized systems for screening recommendations.

Other interventions also have demonstrated promise for increasing colorectal cancer screening rates. Patient navigation, which uses laypersons or health professionals from the community to guide patients through the health-care system, has been demonstrated to be effective at increasing screening, particularly among those of lower socioeconomic status and racial/ethnic minorities (27–29). Patient navigators can be used to assist in obtaining transportation to appointments, provide one-on-one education, assist with understanding and following colonoscopy preparation and FOBT kit instructions, provide reminder calls, and address patient fears (27–29). Although patient navigation programs have been gaining in popularity, the efficacy and cost-effectiveness of these programs has not been well established (30,31). Additional research is needed to define more clearly what constitutes an effective patient navigation program and to assess its cost effectiveness.

In July 2009, to address known barriers to colorectal cancer screening, CDC established the Colorectal Cancer Control Program (CRCCP), and currently funds 25 states and four tribal organizations with the stated goal of increasing colorectal cancer screening prevalence among those aged ≥50 years to 80% in funded states and tribal areas by 2014. CRCCP, which provides colorectal cancer screening services to low-income underinsured and uninsured persons aged 50–64 years, focuses primarily on screening promotion to increase population-level screening. The screening promotion portion of the program encourages grantees to implement evidence-based interventions at an organizational, community, and policy level, where the impact will reach a larger proportion of the target population. Successful implementation of these strategies requires partnership and collaboration with nontraditional public health partners, including health systems, insurers, employers, and professional organizations. For example, a grantee might partner with a health system to implement client or provider reminders in all of its affiliated primary care practices or partner with an employer to implement policies that encourage screening. CDC also funds the National Comprehensive Cancer Control Program, which helps states, tribes, and territories to form coalitions that pool resources through partnerships with multiple organizations to reduce cancer burden in their communities.

The findings provided in this report are subject to at least five limitations. First, colorectal cancer screening rates might be overestimated or underestimated because BRFSS does not specify whether a test was for screening or diagnosis. Second, the survey was conducted only among households with a landline telephone, which might result in certain populations being underrepresented. Third, responses are self-reported and not validated by a review of medical records. Fourth, results might differ from other recent reports of colorectal cancer screening prevalence using BRFSS data (10,11,32). Questions that allow the analysis of screening with colonoscopy or sigmoidoscopy separately were instituted in BRFSS in 2008. In previous reports, sigmoidoscopy and colonoscopy rates were measured and reported as a combined measure (lower endoscopy) to allow analysis of trends in colorectal cancer screening over time (10,11,32). Finally, response rates were low (54.6%), although the BRFSS weighting procedure corrects for nonresponse.

Conclusion

Given the strong association between having health insurance and being up-to-date with colorectal cancer screening, expanding insurance coverage is an important first step to ensuring access to colorectal cancer screening services. Other aspects of the Afforable Care Act also might contribute to increasing access and the use of preventive care services in general, including policies that support expansion of the primary care workforce (ACA §5201–5210), increased funding to community health centers(ACA §10503), and establishment of the Prevention and Public Health Fund (ACA §4002). Additional policies support use of electronic medical records (ACA §4103) and formation of Accountable Care Organizations (ACA §3022), which might lead to better patient care coordination and improved quality. Continued efforts by public health, through partnerships with a wide variety of stakeholders, will be necessary to maximize the potential of these initiatives to increase access to and ensure the equitable distribution and use of colorectal cancer screening services.

References

US Cancer Statistics Working Group. United states cancer Statistics: 1999–2008 incidence and mortality web-based report. Available at: http://www.cdc.gov/uscs. Accessed May 30, 2012.

*The CASRO response rate is the product of three other rates: 1) the resolution rate, which is the proportion of telephone numbers that can be identified as either for a business or residence; 2)the screening rate, which is the proportion of qualified households that complete the screening process; and 3) the cooperation rate, which is the proportion of contacted eligible households for which a completed interview is obtained. CASRO response and cooperation rates reported by different surveys are not strictly comparable because of differences in how disposition catagories are defined.

* Data were weighted to the age, sex, and racial/ethnic distribution of each state's adult population using intercensal estimates and were age-standardized to the 2010 Behavioral Risk Factor Surveillance System (BRFSS) population.

† FOBT within 1 year, or sigmoidoscopy within 5 years with FOBT within 3 years, or colonoscopy within 10 years (United States Preventive Services Task Force, 2008).

* Data were weighted to the age, sex, and racial/ethnic distribution of each state's adult population using intercensal estimates and were age-standardized to the 2010 Behavioral Risk Factor Surveillance System (BRFSS) population.

† FOBT within 1 year, or sigmoidoscopy within 5 years with FOBT within 3 years, or colonoscopy within 10 years (United States Preventive Services Task Force, 2008).

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